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Additionally, interventional cardiology procedure
Interventional
cardiology
Interventional cardiology is a branch of
cardiology that deals specifically with the catheter
based treatment of structural heart diseases.
\- Types Coronary heart disease, Cardiomyopathy
Cardiovascular disease, Ischaemic heart disease, Heart failure,
Hypertensive heart disease, Inflammatory heart disease, Valvular
heart diseas
Andreas Gruentzig {Grüntzig's first successful
coronary angioplasty treatment on a
human was performed in 1977, in Zurich,
Switzerland. He expanded a short, about 3
mm, non-branching section of the Left
Anterior Descending (LAD) artery} is
considered the father of interventional cardiology
after the development of angioplasty by
interventional radiologist, Dr. Charles Dotter.[1]
↕A large number of procedures can be
performed on the heart by catheterization. This
most commonly involves the insertion of a sheath
into the femoral artery (but, in practice, any large
peripheral artery or vein) and cannulating the
heart under X-ray visualization (most commonly
fluoroscopy. The radial artery may also be used
for cannulation; this approach offers several
advantages, including the accessibility of the
artery in most patients, the easy control of
bleeding even in anticoagulated patients, the
enhancement of comfort because patients are
capable of sitting up and walking immediately
following the procedure, and the near absence of
clinically significant sequelae in patients with a
normal Allen test.[2]
The main advantages of using the interventional
cardiologic approach are the avoidance of the
scars and pain, and long post-operative recovery.
Gift of God
of primary angioplasty is now the gold standard of
care for an acute myocardial infarction. It involves
the extraction of clots from occluded coronary
arteries and deployment of stents and balloons
through a small hole made in a major artery(which
has given it the name "pin-hole surgery" (as
opposed to "key-hole surgery"), thereby leaving
no scars.
Procedures performed by specialists in
interventional cardiology:
Angioplasty
Also called percutaneous transluminal
coronary angioplasty (PTCA), angioplasty
is an intervention for the treatment of
coronary artery disease.
Valvuloplasty
It is the dilation of narrowed cardiac
valves (usually mitral, aortic, or
pulmonary).
Congenital heart defect correction
Percutaneous approaches can be employed
to correct atrial septal and ventricular
septal defects, closure of a patent ductus
arteriosus, and angioplasty of the great
vessels.
Percutaneous valve replacement:
An alternative to open heart surgery,
percutaneous valve replacement is the
replacement of a heart valve using percutaneous
methods.
Coronary thrombectomy
Coronary thrombectomy involves the
removal of a thrombus (blood clot) from
the coronary arteries.[3]
Cardiac ablation
A technique performed by clinical
electrophysiologists, cardiac ablation is
used in the treatment of arrhythmias.
Surgery of the heart is termed cardiothoracic
surgery. Some interventional cardiology
procedures are only performed when there is
cardiothoracic surgery expertise in the hospital, in
case of complications.
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ANGIOPLASTY is the technique of mechanically
widening a narrowed or obstructed blood vessel,
typically as a result of atherosclerosis. An empty
and collapsed balloon on a guide wire, known as a
balloon catheter, is passed into the narrowed
locations and then inflated to a fixed size using
water pressures some 75 to 500 times normal
blood pressure (6 to 20 atmospheres). The balloon
crushes the fatty deposits, opening up the blood
vessel for improved flow, and the balloon is then
deflated and withdrawn.
Angioplasty was initially described by
interventional radiologist Charles Dotter in 1964.
[1]
Dr. Dotter pioneered modern medicine with the
invention of angioplasty and the catheter-
delivered stent, which were first used to treat
peripheral arterial disease. On January 16, 1964,
Dotter percutaneously dilated a tight, localized
stenosis of the superficial femoral artery Charles
Dotter is commonly known as the "Father of
Interventional Radiology" and was nominated for
the Nobel Prize in medicine in 1978.
The first coronary angioplasty on an awake patient
was performed by German cardiologist Andreas
Gruentzig in September 1977.[3]
Blockages in the arteries may be caused by
hypertension, diabetes, sedentary lifestyle,
smoking, high cholesterol levels, diets high in
saturated fats, and cardiovascular disease.
Removing blockages is done with angioplasty.[4]
Types
1 Coronary
2 Peripheral { Renal(ptra) , Carotid , Cerebral}
Peripheral angioplasty refers to the use of a
balloon to open a blood vessels outside the
. These stenotic segments are due to the build up of cholesterol-laden plaques that form due to
atherosclerosis. PCI is usually performed by an interventional cardiologist.
Gift of God
coronary arteries. It is commonly done to treat
atherosclerotic narrowings of the abdomen, leg
and renal arteries. PA can also be done to treat
narrowings in veins, etc. Often, peripheral
angioplasty is used in conjunction with peripheral
stenting and atherectomy.
Angioplasties are safer than bypass surgery and
according to statistics less than 1% of people die
from complications after this procedure.
Coronary angioplasty
coronary angioplasty, also known as percutaneous
transluminal coronary angioplasty (PTCA),
because it's done through the skin and through the
lumen of the artery, was first developed in 1977
by Andreas Gruentzig, Switzerland[1].
Angioplasty is sometimes eponymously referred
to as Dottering, after Interventional Radiologist,
Dr Charles Theodore Dotter, who, first described
angioplasty in 1964.[3] As the range of procedures
performed upon coronary artery lumens has
widened, the name of the procedure has changed
to percutaneous coronary intervention (PCI).
Percutaneous coronary intervention can be
performed to reduce or eliminate the symptoms of
coronary artery disease, including angina (chest
pain), dyspnea (shortness of breath) on exertion,
and congestive heart failure. PCI is also used to
abort an acute myocardial infarction, and in some
specific cases it may reduce death.
: Percutaneous coronary
intervention
Percutaneous coronary intervention (PCI),
commonly known as coronary angioplasty is a
therapeutic procedure to treat the stenotic
(narrowed) coronary arteries of the heart found in
coronary heart disease
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Treatment with PCI for patients with stable coronary artery disease reduces chest pain, but does not reduce
the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical
therapy.[13]

Procedures

The term balloon angioplasty is commonly used to describe percutaneous coronary intervention, which
describes the inflation of a balloon within the coronary artery to crush the plaque into the walls of the artery.
While balloon angioplasty is still done as a part of nearly all percutaneous coronary interventions, it is rarely
the only procedure performed.

Other procedures that are done during a percutaneous coronary intervention include:

• Implantation of stents
• Rotational or laser atherectomy ( percutaneous revascularization, which implies re-
canalizing blocked vasculature)
• Brachytherapy (Use of radioactive source to inhibit restenosis.)

Sometimes a small mesh tube, or "stent", is introduced into the blood vessel or artery to prop it open using
percutaneous methods. Angioplasty with stenting is a viable alternative to heart surgery for some forms of
non-severe coronary artery disease.[9] It has consistently been shown to reduce symptoms due to coronary
artery disease and to reduce cardiac ischemia, but has not been shown in large trials to reduce mortality due
to coronary artery disease, except in patients being treated for a heart attack acutely (also called primary
angioplasty). In acute cases, there is a small but definite reduction of mortality with this form of treatment
compared with medical therapy, which usually consists of the administration of thrombolytic ("clot
busting") medication.[10][11]

PROCEDURE

Technique

The angioplasty procedure usually consists of most of the following steps and is performed by physicians,
physician assistants, nurse practitioners, nurses, radiological technologists and cardiac invasive specialist; all
whom have extensive and specialized training in these types of procedures.

1. Access into the femoral artery in the leg (or, less commonly, into the radial artery or
brachial artery in the arm) is created by a device called an "introducer needle". This
procedure is often termed percutaneous access.
2. Once access into the artery is gained, a "sheath introducer" is placed in the opening to
keep the artery open and control bleeding.
3. Through this sheath, a long, flexible, soft plastic tube called a "guiding catheter" is
pushed. The tip of the guiding catheter is placed at the mouth of the coronary artery.
The guiding catheter also allows for radiopaque dyes (usually iodine based) to be
injected into the coronary artery, so that the disease state and location can be readily
assessed using real time x-ray visualization.
4. During the x-ray visualization, the cardiologist estimates the size of the coronary artery
and selects the type of balloon catheter and coronary guidewire that will be used
during the case. Heparin (a "blood thinner" or medicine used to prevent the formation
of clots) is given to maintain blood flow.
5. The coronary guidewire, which is an extremely thin wire with a radio-opaque flexible
tip, is inserted through the guiding catheter and into the coronary artery. While
visualizing again by real-time x-ray imaging, the cardiologist guides the wire through
the coronary artery to the site of the stenosis or blockage. The tip of the wire is then
passed across the blockage. The cardiologist controls the movement and direction of

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the guide wire by gently manipulating the end that sits outside the patient through
twisting of the guidewire.
6. While the guidewire is in place, it now acts as the pathway to the stenosis. The tip of
the angioplasty or balloon catheter is hollow and is then inserted at the back of the
guidewire—thus the guidewire is now inside of the angioplasty catheter. The
angioplasty catheter is gently pushed forward, until the deflated balloon is inside of the
blockage.
7. The balloon is then inflated, and it compresses the atheromatous plaque and stretches
the artery wall to expand.
8. If an expandable wire mesh tube (stent) was on the balloon, then the stent will be
implanted (left behind) to support the new stretched open position of the artery from
the inside.[12]

Coronary stenting

Traditional ("bare metal") coronary stents provide a mechanical framework that holds the artery wall open,
preventing stenosis, or narrowing, of coronary arteries. PTCA with stenting has been shown to be superior to
angioplasty alone in patient outcome by keeping arteries patent for a longer period of time.[13]

Newer drug-eluting stents (DES) are traditional stents that are coated with drugs, which, when placed in the
artery, release certain drugs over time. It has been shown that these types of stents help prevent restenosis of
the artery through several different physiological mechanisms, which rely upon the suppression of tissue
growth at the stent site and local modulation of the body's inflammatory and immune responses. Five drugs,
Biolimus A9[14], Zotarolimus, sirolimus, everolimus and paclitaxel, have demonstrated safety and efficacy in
this application in controlled clinical trials by stent device manufacturers.[citation needed] However, in 2006 three
broad European trials seem to indicate that drug-eluting stents may be susceptible to an event known as "late
stent thrombosis", where the blood-clotting inside the stent can occur one or more years post-stent. Late
stent thrombosis occurs in 0.9% of patients, and is extremely dangerous and is fatal in about one-third of
cases when the thrombosis occurs.[15][16] New generation DES products, such as the BioMatrix stent marketed
by Biosensors International since January 2008 in Europe, seek to eliminate this risk by using a
biodegradable coating.

[edit] After the procedure

After angioplasty, most of the patients are monitored overnight in the hospital but if there are no
complications, the next day, patients are sent home.

The catheter site is checked for bleeding and swelling and the heart rate and blood pressure are monitored.
Usually, patients receive medication that will relax them to protect the arteries against spasms. Patients are
typically able to walk within two to six hours following the procedure and return to their normal routine by
the following week.[10]

Angioplasty recovery consists in avoiding physical activity for several days after the procedure. Patients are
advised to avoid any type of lifting, babysitting grandchildren or other strenuous physical activity for a
week.[11] Patients will need to avoid physical stress or prolonged sport activities for a maximum of two
weeks after a delicate balloon angioplasty.[12]

Patients with stents are usually prescribed an anticoagulant, clopidogrel which is taken at the same time with
acetylsalicylic acid. These medications are intended to prevent blood clots and they are usually taken for at
least the first months after the procedure is performed. In most cases, patients are administrated this type of
medication for 1 year. Also, patients who are doing dental work are advised to cancel it because there is a
risk of endocarditis, an infection of the heart.

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Patients who experience swelling, bleeding or pain at the insertion site, develop fever, feel faint or weak,
notice a change in temperature or color in the arm or leg that was used or have shortness of breath or chest
pain should immediately seek medical advice..

[edit] Risks

Coronary angioplasty is widely practiced and has a number of risks;[17] however, major procedural
complications are uncommon. Coronary angioplasty is usually performed by an interventional cardiologist, a
medical doctor with special training in the treatment of the heart using invasive catheter-based procedures.
[citation needed]

The patient is usually awake during angioplasty, and chest discomfort may be
experienced during the procedure; the reporting of symptoms indicates the procedure
is causing ischemia and the cardiologist may alter or abort part of the procedure.
Bleeding from the insertion point in the groin is common, in part due to the use of
anti-platelet clotting drugs. Some bruising is therefore to be expected, but
occasionally a hematoma may form. This may delay hospital discharge as flow from
the artery into the hematoma may continue (pseudoaneurysm) which requires
surgical repair. Infection at the skin puncture site is rare and dissection (tearing) of
the access blood vessel is uncommon. Allergic reaction to the contrast dye used is
possible, but has been reduced with the newer agents. Tearing of the artery resulting
in total blockage and possible myocardial infarction - this can usually be repaired with
a stentA dislodged clot may cause a stroke in some circumstances (in less than 1% of
patients who undergo angioplasties);Bleeding or bruising where the catheters were
inserted;Kidney problems, especially in people with underlying kidney disease and
diabetes - this is caused by the iodine contrast dye used for the X-ray; intravenous
fluids and medications can be given before and after the procedure to try to reduce
this risk.Arrhythmia (irregular heartbeat);[6]Deterioration of kidney function can occur in
patients with pre-existing kidney disease, but kidney failure requiring dialysis is rare. Vascular
access complications are less common and less serious when the procedure is performed via
the radial artery.[citation needed]

The most serious risks are

death, stroke, VF (non-sustained VT is common), myocardial infarction (heart attack) and Complications
that may occur after or during an angioplasty are the following:

• Allergic reaction to the dye given during the angioplasty;

• Myocardial infarction happens in 3 to 5% of the cases;
• The need for emergency coronary artery bypass grafting during the procedure (2-4
percent of people). This may occur if an artery closes down instead of opening up;
• Restenosis is one of the most common complications of angioplasties and it consists in
the gradual re-narrowing of the blood vessels within the next several weeks to months
after the procedure. There are certain conditions that increase the risk of developing
this complication and these are hypertension, diabetes, angina or kidney disease.
• Blood clots (in-stent thrombosis) can form within stents hours or months after
angioplasty and they may cause myocardial infarction.[7]

aortic dissection.

A heart attack during or shortly after the procedure occurs in 0.3% of cases; this may require emergency
coronary artery bypass surgery.[18] As with any procedure involving the heart, complications can sometimes,
though rarely, cause death. Less than 2 percent of people die during angioplasty. Sometimes chest pain can

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occur during angioplasty because the balloon briefly blocks off the blood supply to the heart. The risk of
complications is higher in:[21]

• People aged 75 and older

• People who have kidney disease or diabetes
• Women
• People who have poor pumping function in their hearts
• People who have extensive heart disease and blockages

Cardiac catheterization (also called cardiac cath or coronary angiogram) is an invasive imaging procedure
that allows evaluate our heart function. Cardiac catheterization is used to.

Evaluate or confirm the presence of coronary artery disease, valve disease or disease of
the aorta ,Evaluate heart muscle function ,Determine the need for further treatment (such
as an interventional procedure or coronary artery bypass graft, or CABG,

Valvuloplasty

Valvuloplasty is the widening of a stenotic valve using a balloon catheter. Types include:

Aortic valvuloplasty in repair of a stenotic aortic valve. Mitral valvuloplasty in the correction of an
uncomplicated mitral stenosis

Radio frequency ablation (RFA) is a medical procedure where part of the electrical conduction system of
the heart, tumor or other dysfunctional tissue is ablated using high frequency alternating current to treat a
medical disorderRadiofrequency energy is used to destroy abnormal electrical pathways in heart tissue or
normal parts that are contributing to a cardiac arrhythmia. It is used in recurrent atrial flutter, atrial
fibrillation (AF), supraventricular tachycardia (SVT) and some types of ventricular arrhythmia. The energy
emitting probe (electrode) is at the tip of a catheter which is placed into the heart, usually through a vein.

interventional procedure

An interventional procedure is a non-surgical treatment used to open narrowed coronary arteries to improve
blood flow to the heart. An interventional procedure can be performed during a diagnostic cardiac
catheterization when a blockage is identified, or it may be scheduled after a catheterization has confirmed
the presence of coronary artery disease.

An interventional procedure starts out the same way as a cardiac catheterization. Once the catheter is in
place, one of these interventional procedures is performed to open the artery: balloon angioplasty, stent
placement, rotablation or cutting balloon.

Balloon angioplasty: A procedure in which a small balloon at the tip of the catheter is inserted near the
blocked or narrowed area of the coronary artery. The technical name for balloon angioplasty is percutaneous
transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI). When the balloon
is inflated, the fatty plaque or blockage is compressed against the artery walls and the diameter of the blood
vessel is widened (dilated) to increase blood flow to the heart. This procedure is sometimes complicated by
vessel recoil and restenosis.

Balloon angioplasty with stenting: In most cases, balloon angioplasty is performed in combination with
the stenting procedure. A stent is a small, metal mesh tube that acts as a scaffold to provide support inside
the coronary artery. A balloon catheter, placed over a guide wire, is used to insert the stent into the narrowed
artery. Once in place, the balloon is inflated and the stent expands to the size of the artery and holds it open.
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The balloon is deflated and removed, and the stent stays in place permanently. During a period of several
weeks, the artery heals around the stent. In this way, restenosis is somewhat diminished.

Angioplasty with stenting is most commonly recommended for patients who have a blockage in one or two
coronary arteries. If there are blockages in more than two coronary arteries, coronary artery bypass graft
surgery may be recommended.

Drug-eluting stents (DES): Drug-eluting stents contain a medication that is actively released at the stent
implantation site. Drug-eluting stents have a thin surface of medication to reduce the risk of restenosis.

Concern was raised in 2006 regarding the safety of drug-eluting stents due to the risk of blood clots forming
on the stent, causing a heart attack. The Food and Drug Administration (FDA) continues to feel that DES,
when used according to approved indications, are safe and effective. Source: Update to FDA Statement on
Coronary Drug-Eluting Stents (January 4, 2007).

If you receive a drug-eluting stent, your doctor will prescribe certain medications for several months after
your procedure to prevent the risk of clotting in the stent. It is extremely important to keep taking the
medications as prescribed until your doctor tells you otherwise.

If you have concerns about drug-eluting stents, please talk with your physician.

Rotablation (Percutaneous Transluminal Rotational Atherectomy or PTRA): A special catheter, with

an acorn-shaped, diamond-coated tip, is guided to the point of narrowing in the coronary artery. The tip
spins around at a high speed and grinds away the plaque on the arterial walls. This process is repeated as
needed to treat the blockage and improve blood flow. The microscopic particles are washed safely away in
your blood stream and filtered out by your liver and spleen.

Cutting balloon: The cutting balloon catheter has a balloon tip with small blades. When the balloon is
inflated, the blades are activated. The small blades score the plaque, then, the balloon compresses the fatty
matter into the arterial wall. This type of balloon may be used to treat the build up of plaque within a
previously placed stent (restenosis) or other types of blockages.

Cardiac monitoring pressures and volumes Pressure Normal values SOURCE: Pagana, K.D. and T.J.
Pagana. Mosby's Diagnostic and Laboratory Test Reference. 3rd ed. St. Louis: Mosby, 1997. Aortic artery
pressure (routine blood pressure) 90–140/60–90 mm Hg Central venous pressure 2–14 cm H2 End-diastolic
left ventricular pressure 4–12 mm Hg Pulmonary wedge pressure Left atrial: 6–15 mm Hg Pulmonary artery
pressure 15–28/5–16 mm Hg Systolic left ventricle pressure 90–140 mm Hg Volumes Cardiac index (CI)
2.8–4.2 L/min/m2 for a patient with 1.5m2 of body surface area Cardiac output (CO) 3–6 L/min Ejection
fraction (EF) 0.67±0.07 End-diastolic volume (EDV) 50–90ml/m2 End-systolic volume (ESV) 25 ml/m2
Stroke volume (SV) 45±12 ml/m2
http://emedicine.medscape.com/article/161446-overview#a30

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